Form 57.150 LTAC Annual 57.150 LTAC Annual 57.150_ LTAC Annual Facility Survey_BLANK 2021

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/TOI-57.150-LTAC.pdf
Page 1 of 17
*required for saving

Tracking #:

*Facility ID:

*Survey Year:

Facility Characteristics (completed by Infection Preventionist)
*Ownership (check one):

□

For profit

□

Not for profit, including
church

□

□

Government

Veterans Affairs

*Affiliation (check one):

□

Hospital system

□

Independent

□

Multi-facility organization
(specialty hospital network)

*Setting/classification:
____ Free-standing
____ Within a hospital
If classified as “Free-standing,” does your LTAC hospital share physical housing with one or more of the following on-site
facilities or units (check all that apply)?

□
□
□
□
□
□

No
Skilled nursing facility (SNF)/nursing home
Residential facility (assisted living)
Inpatient rehabilitation facility
Neuro-behavioral unit or facility
Other (please specify: _______________________________________)

If classified as “Within a hospital,” is your LTAC hospital located:
In a building that does not provide acute care services (e.g., psychiatric hospital)?
Near (but not within) an acute care hospital?

□ Yes
□ Yes

□ No
□ No

In the previous calendar year, indicate:
*Number of patient days:

_____________________

*Number of admissions:

_____________________

*Average daily census:

_____________________

*Numbers of LTAC beds in the following categories (categories should equal total):
a. Intensive care unit (ICU) or critical care beds: _________
b. High observation/special care/high acuity beds (not ICU): _________
c. General LTAC beds: _________
*Total number of LTAC beds (licensed capacity): _________
*Number of single occupancy rooms: _________
*Total number of admissions with one of the following conditions identified on admission (present on
admission, not developing during LTAC stay): (Note: These categories are not mutually exclusive.)
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a
guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the
institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 70 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to
a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).
CDC 57.150 (Front) Rev. 6 , v9.4

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 2 of 17

Facility Microbiology Laboratory Practices (completed with input from Microbiology Laboratory Lead)
If helpful for your facility in identifying these conditions on admission, please review a list of ICD-10 and DRG codes
commonly associated with these conditions found here:
http://www.cdc.gov/nhsn/xls/DRGs-ICD-9s-NHSN-LTAC-Survey.xlsx
a. Ventilator dependence: ________
b. Hemodialysis: _________
*1. Does your facility have its own on-site laboratory that performs bacterial antimicrobial
susceptibility testing?

□ Yes

□ No

1a. If No, where is your facility’s antimicrobial susceptibility testing performed? (check one)

□ Affiliated medical center

□ Commercial referral laboratory

□ Other local/regional, non-affiliated
reference laboratory

*2. For the following organisms please indicate which methods are used for:
(1) Primary susceptibility testing and
(2) Secondary, supplemental, or confirmatory testing (if performed).
If your laboratory does not perform susceptibility testing, please indicate the methods used at the outside laboratory.
Please use the testing codes listed below the table.

Pathogen

(1) Primary

(2) Secondary

Comments

Staphylococcus aureus

_______________

_______________

_______________

Enterobacterales

_______________

_______________

_______________

1 = Kirby-Bauer disk
diffusion
2 = Vitek (Legacy)

4 = Sensititre

7 = Agar dilution method

5.1 = MicroScan WalkAway

10 = E test

2.1 = Vitek 2

5.2 = MicroScan autoSCAN

12 = Vancomycin agar screen (BHI + vancomycin)

3.1 = BD Phoenix

6 = Other broth microdilution method

13 = Other (describe in Comments section)

*3. Does either the primary or secondary/supplemental antimicrobial
susceptibility testing of Pseudomonas spp., include ceftolozane-tazobactam?

□ N/A – no AST
□ Yes

*4. Has the laboratory implemented the revised cephalosporin and monobactam
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010? (As of 2020, this
includes organisms in the order Enterobacterales.)
*5. Has the laboratory implemented the revised carbapenem breakpoints for
Enterobacteriaceae recommended by CLSI as of 2010? (As of 2020, this includes
organisms in the order Enterobacterales.)
*6. Does the laboratory perform a test for presence of carbapenemase? (this does not
include automated testing instrument expert rules)

□ No

performed for
Pseudomonas

□ Yes □ No
□ Yes □ No
□ Yes □ No

6a. If Yes, please indicate what is done if carbapenemase production is detected: (check one)

□ Change susceptible carbapenem results to resistant
□ Report carbapenem MIC results without an interpretation
□ No changes are made in the interpretation of carbapenems, the test is used for epidemiological
or infection control practices
Continued >>
CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 3 of 17

Facility Microbiology Laboratory Practices (continued)
6b. If Yes, which test is routinely performed to detect carbapenemase: (check all that apply)

□ PCR
□ Modified Hodge Test
□ Rapid CARB Blue
□ E test

□ MBL Screen
□ Carba NP
□ Cepheid, BioFire array, Verigene®
□ Other (specify): ______________

□ mCIM/CIM

6c. If Yes, which of the following are routinely tested for the presence of carbapenemases: (check all that apply)

□ Enterobacterales spp.

□ Pseudomonas aeruginosa

□ Acinetobacter baumannii

*7. Does your facility perform extended-spectrum beta-lactamase (ESBL) testing for E. coli
and/or Klebsiella spp. either routinely or using a testing algorithm?

□ Yes

□ No

7a. If Yes, please indicate what is done if ESBL is detected: (check one)

□ Change susceptible Cefotaxime/Ceftriaxone/Cefepime results to resistant
□ No changes are made in the interpretation of cephalosporins with a note of ESBL
□ Suppress cephalosporin susceptibility results
*8. Where is yeast identification performed for specimens collected at your facility? (check the most applicable)

□ On-site laboratory
□ Affiliated medical center
□ Commercial referral laboratory
□ Other local/regional, non-affiliated reference laboratory
□ Yeast identification not available (i.e., yeast identification is not performed onsite or at any affiliate/commercial/other
laboratory) [If checked, skip questions 9-13)

Answer questions 9–13 for the laboratory that performs yeast identification for your facility:
*9. Which of the following methods are used for yeast identification? (check all that apply)

□ MALDI-TOF MS System (Vitek MS)
□ MALDI-TOF MS System (Bruker Biotyper)

□ MicroScan
□ Non-automated Manual Kit (e.g., API 20C, RapID, Germ Tube,

□ Vitek-2
□ BD Phoenix

□ DNA sequencing
□ Other (specify) ______________________

PNA-FISH, etc.)

*10. Does the laboratory routinely use Chromagar for the identification or differentiation of Candida isolates?

□ Yes

□ No

□ Unknown
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 4 of 17

Facility Microbiology Laboratory Practices (continued)
*11. Candida isolated from which of the following body sites are usually fully identified to the species level? (check all that
apply)

□
□
□

Blood
Other normally sterile body site (e.g., CSF)
Urine

□
□
□

Respiratory
Other (specify): _____________________
None are fully identified to the species level

*12. Does the laboratory employ any culture-independent diagnostic tests (CIDT) to identify Candida from blood
specimens?

□ Yes

□ No

□ Unknown

12a. If yes, which culture-independent diagnostic tests (CIDT) are used to identify Candida from blood specimens?
(check all that apply)

□ T2Candida Panel
□ BioFire
□ Other, specify: _________________
□ Unknown
*13. Are any culture-independent diagnostic tests (CIDT) used to specifically identify Candida auris from clinical
specimens?

□ Yes

□ No

□ Unknown

13a. If yes, which culture-independent diagnostic tests (CIDT) are used to identify Candida auris from clinical
specimens? (check all that apply)

□ T2Cauris Panel
□ PCR
□ Other, specify: _______________
□ Unknown
*14. Where is antifungal susceptibility testing (AFST) performed for specimens collected at your facility? (check the most
applicable)

□ On-site laboratory
□ Affiliated medical center
□ Commercial referral laboratory

□ Other local/regional, non-affiliated reference laboratory
□ AFST not available (i.e., AFST is not performed onsite or at any
affiliate/commercial/other laboratory) [if selected, skip questions 15-17]

Answer questions 15–17 for the laboratory that performs AFST for your facility:
*15. What method is used for antifungal susceptibility testing (AFST)? (check all that apply)

□ Broth microdilution
□ Disk diffusion

□ YeastOne colorimetric microdilution
□ Other (specify): ________________

□ E test
□ Unknown

□ Vitek 2 card
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 5 of 17

Facility Microbiology Laboratory Practices (continued)
15a. If Vitek is used for AFST, which Candida species do you test with it? (check all that apply)

□ C. albicans
□ C. glabrata

□ C. parapsilosis
□ Other Candida spp.

*16. AFST is performed for which of the following antifungal drugs? (check all that apply)

□ Fluconazole
□ Voriconazole
□ Itraconazole
□ Posaconazole

□ Micafungin
□ Anidulafungin
□ Caspofungin
□ Amphotericin B

□ Flucytosine
□ Other, specify: ________________
□ Unknown

*17. AFST is performed on fungal isolates in which of the following situations? (check only one box per row)

Blood
Other normally sterile
body site (e.g., CSF)
Urine
Respiratory
Other (specify): ________

Performed
automatically/
reflexively

Performed with a
clinician’s order

Not performed

Unknown

□
□
□
□
□

□
□
□
□
□

□
□
□
□
□

□
□
□
□
□

*18. What is the primary testing method for C. difficile used most often by your facility’s laboratory or the outside
laboratory where your facility’s testing is performed? (check one)

□ Enzyme immunoassay (EIA) for toxin
□ Cell cytotoxicity neutralization assay
□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP)
□ NAAT plus EIA, if NAAT positive (2-step algorithm)
□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)
□ GDH plus NAAT (2-step algorithm)
□ GDH plus EIA for toxin, followed by NAAT for discrepant results
□ Toxigenic culture (C. difficile culture followed by detection of toxins)
□ Other (specify): _______________________________
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 6 of 17

Facility Microbiology Laboratory Practices (continued)

*19. Please indicate the primary and definitive method used to identify microbes from blood cultures collected in your
facility. (check one)

□ MALDI-TOF MS System (Vitek MS)
□ MALDI-TOF MS System (Bruker Biotyper)
□ Automated Instrument (e.g., Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)
□ Non-automated Manual Kit (e.g., API, Crystal, RapID, etc.)
□ Rapid Identification (e.g., Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)
□ 16S rRNA Sequencing
*20. Please indicate any additional secondary methods used for microbe identification from blood cultures collected in
your facility (e.g., a rapid method that is confirmed with the primary method, a secondary method if the primary method
fails to give an identification, or a method that is used in conjunction with the primary method). (check all that apply)

□ MALDI-TOF MS System (Vitek MS)
□ MALDI-TOF MS System (Bruker Biotyper)
□ Automated Instrument (e.g., Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)
□ Non-automated Manual Kit (e.g., API, Crystal, RapID, etc.)
□ Rapid Identification (e.g., Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)
□ 16S rRNA Sequencing
Infection Control Practices (completed with input from Hospital Epidemiologist and/or Quality Improvement
Coordinator)
*21. Number or fraction of infection preventionists (IPs) in facility:
a. Total hours per week performing surveillance:

__________________

b. Total hours per week for infection control activities other than surveillance:

__________________

*22. Number or fraction of full-time employees (FTEs) for a designated hospital
epidemiologist (or equivalent role) affiliated with your facility:

__________________

*23. Is it a policy in your facility that patients infected or colonized with MRSA are routinely placed in contact precautions
while these patients are in your facility? (check one)

□ Yes

□ No

□ Not applicable: my facility never admits these patients

Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 7 of 17

Infection Control Practices (continued)
23a. If Yes, please check the type of patients that are routinely placed in contact precautions while in your facility
(check one):

□ All infected and all colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□ Patients admitted to high risk settings
□ Patients at high risk for transmission
*24. Is it a policy in your facility that patients infected or colonized with VRE are routinely placed in contact precautions
while these patients are in your facility? (check one)

□ Yes
□ No
□ Not applicable: my facility never admits these patients
24a. If Yes, please check the type of patients that are routinely placed in contact precautions while in your facility
(check one):
□ All infected and all colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□ Patients admitted to high risk settings
□ Patients at high risk for transmission
*25. Is it a policy in your facility that patients infected or colonized with CRE (regardless of confirmatory testing for
carbapenemase production) are routinely placed in contact precautions while these patients are in your facility? (check
one)

□ Yes
□ No
□ Not applicable: my facility never admits these patients
25a. If Yes, please check the type of patients that are routinely placed in contact precautions while in your facility
(check one):

□ All infected and all colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□ Patients admitted to high risk settings
□ Patients at high risk for transmission

Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 8 of 17

Infection Control Practices (continued)
*26. Is it a policy in your facility that patients infected or colonized with suspected or confirmed ESBL-producing or
extended spectrum cephalosporin resistant Enterobacterales are routinely placed in contact precautions while these
patients are in your facility? (check one)

□ Yes
□ No
□ Not applicable: my facility never admits these
patients
26a. If Yes, please check the type of patients that are routinely placed in contact precautions while in your facility
(check one):

□ All infected and all colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□ Patients admitted to high risk settings
□ Patients at high risk for transmission
*27. Does the facility routinely perform screening testing (culture or non-culture) for CRE? This includes screening for
patients at your facility performed by public health laboratories and commercial laboratories

□ Yes

□ No

27a. If Yes, in which situations does the facility routinely perform screening testing for CRE? (check all that apply)

□ Surveillance testing at admission for all patients
□ Surveillance testing of epidemiologically-linked patients of newly identified CRE patients (e.g., roommates)
□ Surveillance testing at admission of high-risk patients (check all that apply)
□ Patients admitted from long-term acute care (LTAC) or long-term care facility (LTCF)
□ Patients with recent (e.g., within 6 months) overnight hospital stay outside the United States
□ Patients admitted to high-risk settings (e.g., ICU)
□ Other high-risk patients (please specify): _________________
□ Other (please specify): _________________
*28. Does the facility routinely perform screening testing (culture or non-culture) for MRSA for any patients admitted to
non-NICU settings?

□ Yes

□ No
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 9 of 17

Infection Control Practices (continued)
28a. If yes, in which situations does the facility routinely perform screening testing for MRSA for non-NICU settings?
(check all that apply)

□ Surveillance testing at admission for all patients
□ Surveillance testing at admission of high-risk patients (e.g., admitted from long-term acute care [LTAC] or longterm care facility [LTCF])

□ Surveillance testing at admission of patients admitted to high-risk settings (e.g., ICU)
□ Surveillance testing of pre-operative patients to prevent surgical site infections
□ Other (please specify): _________________
*29. Does the facility routinely perform screening testing (culture or non-culture) for MRSA for any patients admitted to
NICU settings?

□ Yes
□ No
29a. If yes, in which situations does the facility routinely perform screening testing for MRSA for NICU settings? (check
all that apply)
□ Surveillance testing at admission for all transferred patients
□ Surveillance testing of patients from known MRSA positive mothers
□ Surveillance testing of high-risk patients (e.g. infants born premature)
□ Routine active surveillance testing (i.e., point prevalence surveys)
□ Other (please specify): _________________
*30. Does your facility have a policy to routinely use chlorhexidine bathing for any adult
patients?

□ Yes □ No

*31. Does the facility have a policy to routinely use a combination of topical
chlorhexidine AND an intranasal antistaphylococcal agent (mupirocin, iodophor, or an
alcohol based intranasal agent) for any adult patients to prevent healthcare-associated
infections or reduce transmission of resistant pathogens?

□ Yes □ No

□ N/A,
Children’s
Hospital

□ N/A,
Children’s
Hospital

Antibiotic Stewardship Practices
(completed with input from Physician and Pharmacist Stewardship Leaders)
*32. Did the antibiotic stewardship leader(s) participate in responding to these questions? (Check one.)

□ Yes, pharmacist lead
□ Yes, physician lead
□ Yes, both pharmacist and physician leads
□ Yes, other lead
□ No
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 10 of 17

Antibiotic Stewardship Practices (continued)
*33. Facility leadership has demonstrated commitment to antibiotic stewardship efforts by: (Check all that apply.)

□ Providing stewardship program leader(s) dedicated time to manage the program and conduct daily stewardship
interventions.

□ Allocating resources (e.g., IT support, training for stewardship team) to support antibiotic stewardship efforts.
□ Having a senior executive that serves as a point of contact or “champion” to help ensure the program has resources
and support to accomplish its mission.

□ Presenting information on stewardship activities and outcomes to facility leadership and/or board at least annually.
□ Ensuring the stewardship program has an opportunity to discuss resource needs with facility leadership and/or board
at least annually.

□ Communicating to staff about stewardship activities, via email, newsletters, events, or other avenues.
□ Providing opportunities for hospital staff training and development on antibiotic stewardship.
□ Providing a formal statement of support for antibiotic stewardship (e.g., a written policy or statement approved by the
board).

□ Ensuring that staff from key support departments and groups (e.g., IT and hospital medicine) are contributing to
stewardship activities.

□ None of the above
*34. Our facility has a leader or co-leaders responsible for antibiotic stewardship program
management and outcomes.
34a. If Yes, what is the position of this leader? (Check one.)

□ Yes

□ No

□ Physician
□ Pharmacist
□ Co-led by both Pharmacist and Physician
□ Other (e.g., RN, PA, NP, etc.; please specify):________________
34b. If Physician or Co-led is selected, which of the following describes your antibiotic stewardship physician
leader? (Check all that apply.)

□ Has antibiotic stewardship responsibilities in their contract or job description
□ Is physically on-site in your facility (either part-time or full-time)
□ Completed an ID fellowship
□ Completed a certificate program on antibiotic stewardship
□ Completed training courses (e.g., conferences or online modules) on antibiotic stewardship
□ None of the above
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 11 of 17

Antibiotic Stewardship Practices (continued)
34c. If ‘Has antibiotic stewardship responsibilities in their contract or job description’ is selected (for physician
(co) leader): What percent time for antibiotic stewardship activities is specified in the physician (co) leader’s
contract or job description? (Check one.)

□ 1-25%
□ 26-50%

□ 51-75%
□ 76-100%

□ Not specified

34d. If Physician or Co-led is selected: In an average week, what percent time does the physician (co) leader
spend on antibiotic stewardship activities in your facility? (Check one.)

□ 1-25%
□ 26-50%
□ 51-75%

□ 76-100%
□ Not specified

34e. If Pharmacist or Co-led is selected, which of the following describes your antibiotic stewardship pharmacist
leader? (Check all that apply.)

□ Has antibiotic stewardship responsibilities in their contract or job description
□ Is physically on-site in your facility (either part-time or full-time)
□ Completed a PGY2 ID residency and/or ID fellowship
□ Completed a certificate program on antibiotic stewardship
□ Completed training courses (e.g., conferences or online modules) on antibiotic stewardship
□ None of the above
34f. If ‘Has antibiotic stewardship responsibilities in their contract or job description’ is selected (for pharmacist
(co) leader): What percent time for antibiotic stewardship activities is specified in the pharmacist (co) leader’s
contract or job description? (Check one)

□ 1-25%
□ 26-50%
□ 51-75%

□ 76-100%
□ Not specified

34g. If ‘Pharmacist’ or ‘Co-led’ is selected: In an average week, what percent time does the pharmacist (co) leader
spend on antibiotic stewardship activities in your facility? (Check one)

□ 1-25%
□ 26-50%
□ 51-75%

□ 76-100%
□ Not specified

34h. If Pharmacist or Other is selected: Does your facility have a designated physician who can serve as a point of
contact and support for the non-physician leader?

□ Yes

□ No

34i. If a pharmacist is not the leader or co-leader for the program, is there at least one pharmacist responsible for
improving antibiotic use at your facility?

□ Yes
CDC 57.103(Back), Rev11, v9.2

□ No

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 12 of 17

Antibiotic Stewardship Practices (continued)
*35. Our facility has the following priority antibiotic stewardship interventions: (Check all that apply)

□ Prospective audit and feedback for specific antibiotic agents
35a. If Prospective audit and feedback is selected: For which categories of antimicrobials? Please answer for the
following categories of antimicrobials, whether or not they are on formulary. (Check all that apply)

□ Cefepime, ceftazidime, or piperacillin/tazobactam
□ Vancomycin (intravenous)
□ Ertapenem, imipenem/cilastatin, or meropenem
□ Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, imipenem-cilastatin/relebactam, or
cefiderocol

□ Fluoroquinolones
□ Daptomycin, linezolid, or other newer anti-MRSA agents
□ Eravacycline or omadacycline
□ Lefamulin
□ Aminoglycosides
□ Colistin or polymyxin B
□ Anidulafungin, caspofungin, or micafungin
□ Isavuconazole, posaconazole, or voriconazole
□ Amphotericin B and/or lipid-based amphotericin B
□ None of the above
35b. If Prospective audit and feedback is selected: Our antibiotic stewardship program monitors prospective audit
and feedback interventions (e.g., by tracking antibiotic use, types of interventions, acceptance of recommendations).

□ Yes

□ No

□ Preauthorization for specific antibiotic agents.
35c. If Preauthorization is selected: For which categories of antimicrobials? Please only answer for categories of
antimicrobials that are on formulary. (Check all that apply)

□ Cefepime, ceftazidime, or piperacillin/tazobactam
□ Vancomycin (intravenous)
□ Ertapenem, imipenem/cilastatin, or meropenem
□ Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, imipenem-cilastatin/relebactam, or
cefiderocol

□ Fluoroquinolones
□ Daptomycin, linezolid, or other newer anti-MRSA agents
□ Eravacycline or omadacycline
□ Lefamulin
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 13 of 17

Antibiotic Stewardship Practices (continued)

□ Aminoglycosides
□ Colistin or polymyxin B
□ Anidulafungin, caspofungin, or micafungin
□ Isavuconazole, posaconazole, or voriconazole
□ Amphotericin B and/or lipid-based amphotericin B
□ None of the above
35d. If Preauthorization is selected: Our antibiotic stewardship program monitors preauthorization interventions (e.g.,
by tracking which agents are requested for which conditions).

□ Yes

□ No

□ Facility-specific treatment recommendations, based on national guidelines and local pathogen susceptibilities, to
assist with antibiotic selection for common clinical conditions (e.g., community acquired pneumonia, urinary tract
infection, skin and soft tissue infection).
35e. If Facility-specific treatment recommendations is selected: Our stewardship program monitors adherence to our
facility’s treatment recommendations for antibiotic selection for common clinical conditions (e.g., community acquired
pneumonia, urinary tract infection, skin and soft tissue infection).

□ Yes

□ No

□ None of the above
*36. Our facility has a policy or formal procedure for other interventions to ensure optimal use of antibiotics: (Check all that
apply.)

□ Early administration of effective antibiotics to optimize the treatment of sepsis
□ Treatment protocols for Staphylococcus aureus bloodstream infection
□ Stopping unnecessary antibiotic(s) in new cases of Clostridioides difficile infection (CDI)
□ Review of culture-proven invasive (e.g., bloodstream) infections
□ Review of planned outpatient parenteral antibiotic therapy (OPAT)
□ The treating team to review antibiotics 48-72 hours after initial order (i.e., antibiotic time-out).
□ Assess and clarify documented penicillin allergy
□ Using the shortest effective duration of antibiotics at discharge for common clinical conditions (e.g. communityacquired pneumonia, urinary tract infections, skin and soft tissue infections)

□ None of the above
36b. If ‘Using the shortest effective duration of antibiotics at discharge for common clinical conditions’ is selected: Our
stewardship program monitors adherence to use of shortest effective duration of antibiotics at discharge for common
clinical conditions (e.g. community-acquired pneumonia, urinary tract infections, skin and soft tissue infections), at
least annually.

□ Yes

□ No
Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 14 of 17

Antibiotic Stewardship Practices (continued)

*37. Our facility has in place the following specific ‘pharmacy-based’ interventions: (Check all that apply)

□ Pharmacy-driven changes from intravenous to oral antibiotics without a physician’s order (e.g., hospital-approved
protocol)

□ Alerts to providers about potentially duplicative antibiotic spectra (e.g., multiple antibiotics to treat anaerobes)
□ Automatic antibiotic stop orders in specific situations (e.g., surgical prophylaxis)
□ None of the above
*38. Our stewardship program has engaged bedside nurses in actions to optimize antibiotic use.

□ Yes

□ No

38a. If Yes is selected: Our facility has in place the following specific ‘nursing-based’ interventions: (Check all that
apply.)

□ Nurses receive training on appropriate criteria for sending urine and/or respiratory cultures.
□ Nurses initiate discussions with the treating team on switching from intravenous to oral antibiotics.
□ Nurses initiate antibiotic time-out discussions with the treating team.
□ Nurses track antibiotic duration of therapy
38b. If ‘Nurses track antibiotic duration of therapy’ is selected: Is that information available at the bedside (e.g., on a
whiteboard in the room)?

□ Yes

□ No

*39. Our stewardship program monitors: (Check all that apply.)

□ Antibiotic resistance patterns (either facility- or region-specific), at least annually
□ Clostridioides difficile infections (or C. difficile LabID events), at least annually
□ Antibiotic use in days of therapy (DOT) per 1000 patient days or days present, at least quarterly
□ Antibiotic use in defined daily doses (DDD) per 1000 patient days, at least quarterly
□ Antibiotic expenditures (i.e., purchasing costs), at least quarterly
□ Antibiotic use in some other way, at least annually (please specify): ___________________
□ None of the above
*40. Our stewardship team provides the following reports on antibiotic use to prescribers, at least annually: (Check all that
apply.)

□ Individual, prescriber-level reports
□ Unit- or service-specific reports
□ None of the above

Continued >>
CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 15 of 17

Antibiotic Stewardship Practices (continued)
40a. If ‘Individual, prescriber-level reports’ or ‘Unit- or service-specific reports’ is selected: Our stewardship
program uses these reports to target feedback to prescribers about how they can improve their antibiotic
prescribing, at least annually.

□ Yes

□ No

□ Yes

□ No

*41. Our facility distributes an antibiogram to prescribers, at least annually

*42. Information on antibiotic use, antibiotic resistance, and stewardship efforts is reported to hospital staff, at least
annually.

□ Yes

□ No

*43. Which of the following groups receive education on optimal prescribing, adverse reactions from antibiotics, and
antibiotic resistance at least annually? (Check all that apply.)

□ Prescribers
□ Nursing staff
□ Pharmacists
□ None of the above
*44. Are patients provided education on important side effects of prescribed antibiotics?

□ Yes

□ No

44a. If ‘Yes’ is selected: How is education to patients on side effects shared? (Check all that apply.)

□ Discharge paperwork
□ Verbally by nurse
□ Verbally by pharmacist
□ Verbally by physician
□ None of the above
Optional Antibiotic Stewardship Practices Questions
Responses to the following questions are not required to complete the annual survey.
Please provide additional information about your facility’s antibiotic stewardship activities and leadership.
45. Antibiotic stewardship activities are integrated into quality improvement and/or patient safety initiatives.

□ Yes

□ No

46. Our facility accesses targeted remote stewardship expertise (e.g., tele-stewardship to obtain facility-specific support
for our antibiotic stewardship efforts

□ Yes

CDC 57.103(Back), Rev11, v9.2

□ No
Continued >>

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 16 of 17

Optional Antibiotic Stewardship Practices (continued)
47. Our stewardship program works with the microbiology laboratory to implement the following interventions:
(Check all that apply)

□ Selective reporting of antimicrobial susceptibility testing results
□ Placing comments in microbiology reports to improve prescribing
□ None of the above
48. Which committees or leadership entities provide oversight of your facility’s antibiotic stewardship efforts? (Check all
that apply.)

□ Pharmacy director
□ Pharmacy & therapeutics
□ Patient safety
□ Quality improvement
□ Executive leadership (e.g., CEO, CMO)

□ Executive leadership (e.g., CEO, CMO)
□ Hospital board
□ Other (please specify): _____________
□ None

Facility Water Management Program (WMP) (Completed with input from WMP team members.)
*49. Has your facility ever conducted an environmental assessment to identify where Legionella and other opportunistic
waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous
mycobacteria, and fungi) could grow and spread in the facility water system (e.g., piping infrastructure)? This may include
a basic diagram that maps all water supply sources, treatment systems, processing steps, control measures, and end-use
points.

□ Yes

□ No

49a. If Yes, when was the most recent assessment conducted? (Check one)

□ Within the most recent year

□ Between 1 and 3 years ago

□ More than 3 years ago

(< 1 year ago)

(≥ 1 year and ≤ 3 years)

(> 3 years)

*50. Has your facility has ever conducted a water infection control risk assessment (WICRA) to evaluate water sources,
modes of transmission, patient susceptibility, patient exposure, and program preparedness? An example WICRA tool can

be accessed at https://www.cdc.gov/hai/pdfs/prevent/water-assessment-tool-508.pdf

□ Yes

□ No

50a. If Yes, when was the most recent assessment conducted? (Check one)

□ Within the most recent year

□ Between 1 and 3 years ago

□ More than 3 years ago

(< 1 year ago)

(≥ 1 year and ≤ 3 years)

(> 3 years)

*51. Does your facility have a water management program (WMP) to prevent the growth and transmission of Legionella
and other opportunistic waterborne pathogens?

□ Yes

□ No

Continued >>

CDC 57.103(Back), Rev11, v9.2

Form Approved
OMB No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Page 17 of 17

Facility Water Management Program (WMP) (continued)
51a. If Yes, who is represented on your facility WMP team? (Check all that apply)

□ Hospital Epidemiologist/ Infection Preventionist
□ Hospital Administrator/Leadership
□ Facilities Manager/ Engineer
□ Maintenance Staff
□ Equipment/Chemical Acquisition/Supplier
□ Environmental Services

□ Compliance/ Safety Officer
□ Risk/Quality Management Staff
□ Infectious Disease Clinician
□ Consultant
□ Laboratory Staff
□ Other (please specify): ____________________

*52. Does your facility regularly monitor the following parameters in the building water system(s)? (Check all that apply)
Disinfectant (such as residual chlorine):
If Yes, does your facility have a plan for corrective actions when disinfectant(s) are
not within acceptable limits as determined by the water management program?

□ Yes
□ Yes

□ No
□ No

Temperature:
If Yes, does your facility have a plan for corrective actions when temperatures are
not within acceptable limits as determined by the water management program?

□ Yes
□ Yes

□ No
□ No

Heterotropic plate counts:
If Yes, does your facility have a plan for corrective actions when heterotrophic plate
counts are not within acceptable limits as determined by the water management
program?

□ Yes

□ No

□ Yes

□ No

Specific environmental testing for Legionella:
If Yes, does your facility have a plan for corrective actions when environmental
testing for Legionella are not within acceptable limits as determined by the water
management program?

□ Yes

□ No

□ Yes

□ No

CDC 57.103(Back), Rev11, v9.2